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The transtheoretical model in health psychology assesses an individual's readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual through the stages of change to action and maintenance.

The transtheoretical model is also known by the acronym "TTM"[1] and by the term "stages of change model"[2][3]. A popular book[4] and articles in the newsmedia[5][6][7][8][9] have discussed the model. It is "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted exceptional criticism" [10].

History and core constructs of the model

James O. Prochaska of the University of Rhode Island and colleagues developed the transtheoretical model beginning in 1977[11]. It is based on an analysis of different theories of psychotherapy[12], hence the name "transtheoretical." The original model consisted of four variables: "preconditions for therapy," "processes of change," "content to be changed," and "therapeutic relationship"[13].

Prochaska and colleagues later refined the model on the basis of research that they published in peer-reviewed journals and books[14][15][16][17][18][19][20][21][22][23][24][25][26][27]. By 1997, the model consisted of five "core constructs": "stages of change," "processes of change," "decisional balance," "self-efficacy," and "temptation"[26].

Stages of change

In the transtheoretical model as of 1997, change is a "process involving progress through a series of six stages"[26]:

Precontemplation - "people are not intending to take action in the foreseeable future, usually measured as the next 6 months"

Contemplation - "people are intending to change in the next 6 months"

Preparation - "people are intending to take action in the immediate future, usually measured as the next month"[nb 1]

Action - "people have made specific overt modifications in their life styles within the past 6 months"

Maintenance - "people are working to prevent relapse," a stage which is estimated to last "from 6 months to about 5 years"

Termination - "individuals have zero temptation and 100% self-efficacy... they are sure they will not return to their old unhealthy habit as a way of coping"[nb 2]

In addition, the researchers conceptualized "relapse" (recycling) which is not a stage in itself but rather the "return from action or maintenance to an earlier stage"[26][nb 3].

Processes of change

The 10 processes of change are "covert and overt activities that people use to progress through the stages"[26]. These processes are most emphasized at different transitions between stages of change[26][nb 4]:

For movement from precontemplation to contemplation, the processes of "consciousness raising," "dramatic relief," and "environmental reevaluation" are emphasized.

Between contemplation and preparation, "self-reevaluation" is emphasized.

To progress through the early stages, people apply cognitive, affective, and evaluative processes. As people move toward maintenance or termination, they rely more on commitments, conditioning, contingencies, environmental controls, and support.[28]

Prochaska and colleagues state that their research related to the transtheoretical model suggests that interventions to change behavior must be "stage-matched," that is, "matched to each individual’s stage of change"[26].

Decisional balance

This core construct "reflects the individual’s relative weighing of the pros and cons of changing"[26][nb 6].

Self-efficacy

This core construct is "the situation-specific confidence people have that they can cope with high risk situations without relapsing to their unhealthy or high risk habit"[26][nb 7].

Temptation

This core construct "reflects the intensity of urges to engage in a specific habit when in the midst of difficult situations"[26][nb 8].

Controversy

Among the criticisms of the model are the following:

Little experimental evidence exists to suggest that application of the model is actually associated with changes in health-related behaviors.

A second systematic review from 2003 asserted that "no strong conclusions" can be drawn about the effectiveness of interventions based on the transtheoretical model for the prevention of pregnancy and sexually transmitted disease[30].

A 2005 systematic review of 37 randomized controlled trials claimed that "there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change"[31].

According to a randomized controlled trial published in 2006, a stage-matched intervention for smoking cessation in pregnancy was more effective than a non-stage-matched intervention, but this finding could have resulted from the "greater intensity" of the stage-matched intervention[32].

A randomized controlled trial published in 2009 found "no evidence" that a smoking cessation intervention based on the transtheoretical model was more effective than a control intervention that was not tailored for stage of change[33].

A 2009 review stated that "existing data are insufficient for drawing conclusions on the benefits of the transtheoretical model" as related to dietary interventions for people with diabetes[34].

In a 2002 review, the model's stages were characterized as "not mutually exclusive"; furthermore, there was "scant evidence of sequential movement through discrete stages"[38].

Responses to such criticisms include:

Many studies that show the model to be ineffective have tailored interventions only to stage of change; if the studies had tailored interventions based on all core constructs of the model, they might have shown positive findings[39]. In particular, the "processes of change" have been characterized as "under-researched"[10]. A 2007 meta-analysis of tailored print health behavior change interventions found that the "number and type of theoretical concepts tailored on," including stage of change and processes of change, were associated with behavior change[40]. In 2008 Hutchison and colleagues published a systematic review of 34 articles examining 24 interventions based on the transtheoretical model for behavior change in physical activity; only 7 of the 24 interventions addressed all four dimensions "stages of change," "processes of change," "decisional balance," and "self-efficacy"[41].

Studies that find the model ineffective are poorly designed; for example, they have small sample sizes, poor recruitment rates, or high high loss to follow-up[39][42][43].

The conversion of continuous data into discrete categories is necessary for the model, similar to how decisions are made about the treatment of high cholesterol levels depending on the discrete category the cholesterol level is placed into[39].

See also

Notes

The following notes summarize major differences between the well-known 1983[15], 1992[23], and 1997[26] versions of the model. Other published versions may contain other differences. For example, Prochaska, Prochaska, and Levesque (2001)[27] do not mention the Termination stage, Self-efficacy, or Temptation.

^ In the 1983 version of the model, the Termination stage is absent. In the 1992 version of the model, Prochaska et al. showed Termination as the end of their "Spiral Model of the Stages of Change," not as a separate stage.

^ In the 1983 version of the model, Relapse is considered one of the five stages of change.

^ In the 1983 version of the model, the processes of change were said to be emphasized in only the Contemplation, Action, and Maintenance stages.

^ In the 1983 and 1992 versions of the model, Prochaska et al. called this process "reinforcement management," not "contingency management."

^ In the 1983 version of the model, "decisional balance" is absent. In the 1992 version of the model, Prochaska et al. mention "decisional balance" but in only one sentence under the "key transtheoretical concept" of "processes of change."

^ In the 1983 version of the model, "self-efficacy" is absent. In the 1992 version of the model, Prochaska et al. mention "self-efficacy" but in only one sentence under the "key transtheoretical concept" of "stages of change."

^ Prochaska JO, Norcross JC, DiClemente CC. Changing for good: the revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits. New York: W. Morrow; 1994. ISBN 0688112633.

^ Miller, Kay. Revolving resolutions - Year after new year, we vow to lose weight, stop smoking, find love or a better job -- only to fail. A few simple strategies could set us straight. Star Tribune: Newspaper of the Twin Cities 2001 Dec 29.